Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement
2015 (English)In: Nutrition & Dietetics, ISSN 1446-6368, E-ISSN 1747-0080, Vol. 72, no 1, 74-80 p.Article in journal (Refereed) Published
High-quality documentation in patient records is essential for patient safety and plays a prominent role in the delivery and evaluation of dietetic/nutrition care. We aimed to evaluate dietitians' documentation in patient records according to the four steps in the Nutrition Care Process: assessment, diagnosis, intervention and monitoring/evaluation.
A retrospective audit of 147 systematically collected outpatient dietetic notes from primary care centres and hospitals in central Sweden was performed using a validated audit instrument. The instrument was used to assess the documentation of 14 items: 10 items focusing on the Nutrition Care Process steps and four items on language clarity and structure, with a maximum total score of 26 for each dietetic note. The notes were divided into three different quality levels, A (high score), B (medium score) or C (low score). Comparisons were made between notes from primary care and hospitals.
The audit showed that the majority of the notes were placed at level B, scoring 13.5–19.5. Only 3% of the notes scored higher than 19.5. The most frequently documented items were intervention (90%), evaluation (70%) and nutrition problem (56%), whereas the least documented items were nutrition prescription (15%), goal of intervention (9%) and connection of problem-etiology-symptom (5%). Flaws in lingual clarity were common (72%). Primary care notes received higher scores than those from hospitals.
The audit shows that Swedish dietetic documentation needs to be improved, for example, by further training and education in the Nutrition Care Process and its standardised terminology.
Place, publisher, year, edition, pages
2015. Vol. 72, no 1, 74-80 p.
Other Social Sciences Nutrition and Dietetics
Research subject Food, Nutrition and Dietetics
IdentifiersURN: urn:nbn:se:uu:diva-230205DOI: 10.1111/1747-0080.12128ISI: 000352153400012OAI: oai:DiVA.org:uu-230205DiVA: diva2:739203